National & International Licence Application/Renewal 2012 FiA Licence Levels: Circuit Licences (inc historic): PCC, CC, PC, NC, ICA, ICB, ICC, H1, H4 Off Road Licences: NOJ, NO, NON, NONJ, NOS Rally Licences: NRNJ, NRJ, CRN, CR, NRN, NR, IRN, IR Received Stamp Here Licences: PSKJ, PSK, NSKJ, NSK, ISK (office use only) CAMS Member Number: (ALL LICENCES ARE VALID FOR LEVEL 2 ACTIVITY) Type of licence(s) applied for:

Your Fixed Expiry Date:

Next Medical Due:

Next Stress ECG Due:

Personal Details (begin completing form here)

Surname:

Given names:

Address:

Town/Suburb: Post Code:

Telephone: Work: ( ) Home: ( ) Mobile:

Fax: ( ) Please attach Email: a passport size Email is used to inform CAMS members of news and updates and is not given to any third party. photo here Date of birth: / / 19 (if not previously supplied) Gender: Female Male

Emergency contact (1): Name: Phone: ( )

Emergency contact (2): Name: Phone: ( )

Do you have Australian citizenship If ‘No’ nationality of passport, Yes No AND see Notes for Application – or permanent residency? Nationality. CAMS-Affiliated Club Membership Please list the CAMS-affiliated car club(s) of which you are a member (no abbreviations): Note: it is compulsory for all CAMS driver/navigator licence holders to be a member of a CAMS-affiliated car club.

Full name of club (1): State:

Full name of club (2): State: Now…continue to section 2

Office Use Only TYPE OF MEDICAL CAMS Member Number: International National Medical Expiry: / /

Receipt No: Date: / / Amount: $ www.cams.com.au ©Confederation of Australian Motor Sport Ltd 2012 CAMS HOTLINE 1300 883 959 Page 1 Licence Selection

Note Minimum Note Minimum Select Licences ages in brackets ages in brackets Tick the boxes next to the licence(s) you require Circuit Rally ICA International Circuit A (17) $ 1,650 IR International Rally (16) $ 423 ICB International Circuit B (17) $ 1,545 IRN International Rally Navigator (16) $ 423 ICC International Circuit C (17) $ 1,445 NR National Rally (16) $ 211 NC National Circuit (17) $ 428 NRN National Rally Navigator (16) $ 211 PC Provisional Circuit (16) $ 428 CR Clubman Rally (16) $ 150 CC Clubman Circuit (16) $ 263 CRN Clubman Rally Navigator (16) $ 150 PCC Provisional Clubman Circuit (16) $ 263 NRJ National Rally Junior (14) $ 46 NRNJ National Rally Junior Navigator (14) $ 46 Historic H1 International (17) $ 490 Off Road H4 International Regularity (17) $ 237 NOS National Off Road Stadium (16) $ 196 NO National Off Road (16) $ 196 Superkart NOJ National Off Road Junior (14) $ 46 ISK International Superkart (16) $ 743 NON National Off Road Navigator (16) $ 196 NSK National Superkart (16) $ 330 NONJ National Off Road Navigator Junior (12) $ 46 NSKJ National Superkart Junior (12) $ 125 PSK Provisional Superkart (16) $ 330 PSKJ Provisional Superkart Junior (12) $ 125 If you have selected more than one licence type please write the most expensive amount here $

OPTIONS AIMSS Levy: Australian Institute of Motor Sport Safety founded by CAMS is the driving force for the improvement of safety in $10 ü Motor Sport in Australia. To learn more please refer to: http://www.aimss.com.au (Levy not applicable to Junior Licences)

Urgent Fee: Required if the licence is needed within 5 working days of application being received by CAMS. This does not $70 include the Australia Post delivery times.

CAMS Manual: The complete CAMS manual is available online at www.camsmanual.com.au . If you would also like us to send you a printed copy, you may select this option.

Grand Total: $

Payment I am paying by: Cash (ONLY if paying in person at your club or CAMS State Office) Cheque made payable to “Confederation of Australian Motor Sport Limited” Money Order made payable to “Confederation of Australian Motor Sport Limited” Credit Card – complete your details below:

Visa MasterCard Card number: Expiry date: /

Name on card: Cardholder signature:

www.cams.com.au ©Confederation of Australian Motor Sport Ltd 2012 CAMS HOTLINE 1300 883 959 Page 2 New Licence Conditions PRE LICENCE LECTURE All new licence applicants are required to complete an online lecture on the requirements of the CAMS Manual of and procedures involved in their particular discipline.

N.B. If you have completed a valid Pre Licence Lecture in the last 24 months for the relevant discipline, you are not required to repeat this lecture.

CAMS Customer Services will automatically enrol you in this course upon receipt of your application. Login details and guidelines will be sent to your nominated email account. I acknowledge that I am required to undertake an online lecture as a condition of receiving this licence.

OBSERVED LICENCE TEST

Are you : • Under the age of 25years? • Applying for a new licence in the following disciplines: Superkart; Off-Road Stadium? • Over the age of 25 years, applying for a Rally licence and not held a commercial road licence for over 5 years? • Applying for a Provisional Circuit or Provisional Clubman Circuit Licence and have NOT :- • competed in 5 CAMS Multi-Car (supersprint) or Regularity events within the last 24 months; OR • competed in 2 CAMS Tarmac Rally events within the last 24 months; OR • held a CAMS PCC/PC/PSK/NSK in the last four years. • Applying for a National Circuit or Clubman Circuit Licence and have NOT :- • held an AKA B-Grade licence (or higher) OR a CAMS NSK/ISKC licence; OR • previously held a CAMS NC (or higher) licence in the last 4 years. N.B. Evidence of competition history must be submitted with this application

If you meet any of the previous criteria, you will need to complete an Observed Licence Test.

An Observed Licence Test is where your driving style, ability and attitude are evaluated in simulated race conditions. Upon receipt of your application, CAMS will issue you with a Pre-Licence Authority (PLA) form which you will need to take with you along to your Observed Llicence Test. The cost and process varies from State to State.

Please contact CAMS on 1300 883 959 for assistance in booking your Observed Licence Test. I acknowledge that I am required to complete an Observed Licence Test prior to receiving my licence.

For further information regarding Observed Licence Tests, please refer to the Licence Section in the CAMS Manual of Motor Sport, which can be found online at www.camsmanual.com.au.

Renewal Conditions

For International A and B licences you must have been observed in one International event in the last 12 months.

For International C Circuit you need to have participated or been observed in one International event or two CAMS Events in the last 24 months.

For Superkart Racing you need to have competed in at least one CAMS permitted event in the past 2 years.

For International Rally you need to have participated in one International or two CAMS Rally events in the last 2 years.

For Circuit, Rally and Off-Road Racing you need to have competed in at least in at least one CAMS permitted event in the past 4 years.

Please contact CAMS if you have not met the above requirements.

Please list the most recent CAMS or International event that you have participated in for each licence discipline.

Discipline : Event : Date :

Discipline : Event : Date : www.cams.com.au ©Confederation of Australian Motor Sport Ltd 2012 CAMS HOTLINE 1300 883 959 Page 3 Health Statement CAMS has made changes to the Medical Evaluation Process to ensure the safest possible driving conditions for all competitors, officials and spectators. Please complete the following section carefully and accurately.

Medical History

Do you have or have you ever had any significant or recurrent problems with the following?

Diabetes Yes No

Heart Disease / Chest Pain Yes No

Epilepsy Yes No

Fits / Fainting / Dizziness Yes No

Anxiety / depression or other mental health condition Yes No

Headaches / Migraine / Head Injury Yes No

N.B. If you answered ‘Yes’ to any of the questions above then you must supply a report from your GP or Specialist Doctor. Further details about this requirement and a copy of the CAMS Medical Statement are available on the CAMS website.

Other Conditions

Do you suffer from any allergies? Yes No

Do you wear glasses or contact lenses when driving? Yes No

Do you suffer from Hearing Loss or Deafness? Yes No

Is there any other relevant medical information that you wish to advise us of?

Medical Assessment Requirements Are you : • Applying for a new or renewed International Licence? • Applying for a new Circuit, Historic, Superkart or Off-Road Stadium Licence? • Age 45 or over and applying for a new or renewed Circuit, Historic, Superkart or Off-Road Stadium Licence?

If you ticked any of the above you must submit a Medical Report to CAMS filled in by your General Practitioner or Specialist.

N.B. Applicants over 45 years of age are required to undergo a Medical Examination every second year only.

www.cams.com.au ©Confederation of Australian Motor Sport Ltd 2012 CAMS HOTLINE 1300 883 959 Page 4 Declaration Statement to be read and completed by applicant: I agree to be bound by the rules and regulations of the event and the provisions of the National Competition Rules of the Confederation of Australian Motor Sport Limited (“CAMS”) and the International Sporting Code of the Federation Internationale d’Automobile (FIA). In exchange for being able to attend or participate in the event, I agree: • to release CAMS and Australian Motor Sports Commission Ltd, promoters, sponsor organisations, land owners and lessees, organisers of the event, their respective servants, officials, representatives and agents (collectively, the “Associated Entities”) from all liability for my death, personal injury (including burns), psychological trauma, loss or damage (including property damage) (“harm”) howsoever arising from my participation in or attendance at the event, except to the extent prohibited by law; • that CAMS and the Associated Entities do not make any warranty, implied or express, that the event services will be provided with due care and skill or that any materials provided in connection with the services will be fit for the purpose for which they are supplied; and • to attend or participate in the event at my own risk. I/we acknowledge that: • the risks associated with attending or participating in the event include the risk that I may suffer harm as a result of: • motor vehicles (or parts of them) colliding with other motor vehicles, persons or property; • acts of violence and other harmful acts (whether intentional or inadvertent) committed by persons attending or participating in the event; and • the failure or unsuitability of facilities (including grand-stands, fences and guard rails) to ensure the safety of persons or property at the event. • Motor sport is dangerous and that accidents causing harm can and do happen and may happen to me. I accept the conditions of, and acknowledge the risks arising from, attending or participating in the event and being provided with the event services by CAMS and the Associated Entities. I understand that this disclaimer is not intended to exclude any valid claim I may have under the CAMS Personal Insurance Scheme. I certify that the statements made to CAMS regarding my psychological and physical conditions and any previous illness are true and accurate. I declare that, should any medical condition arise which would impact on my ability to participate during the currency of this licence, I agree to abstain from exercising the privileges of this licence and to notify CAMS and submit to further medical examination, the results of which are to be forwarded to CAMS’ medical assessor. I undertake not to use any drugs or medication that might be considered illegal and/or use any drugs, medications or practices which contravene the CAMS Anti-Doping Policy. I agree to undertake any drug analysis tests, including any for alcohol that may be considered necessary by CAMS. I authorise any hospital or medical practitioner to furnish information relevant to my medical condition to CAMS’ medical assessor in order to determine competition fitness. FIA requirement: I undertake to make no use of drugs or of prohibited methods such as are defined in chapters I, II, III of Appendix A of the Anti-Doping Code of the Olympic movement (on the recommendation of World Anti-Doping Agency) and the Anti-Doping Regulations of the FIA. For female applicants: I agree to abstain from exercising the privileges of this licence while pregnant.

Any applicant making a false declaration is liable to refusal and cancellation of licence and/or insurance cover

Applicant’s Date: / / signature: SIGN HERE

Consent Statement For Applicants Under 18 Years

Are you under 18 years of age? Yes No Parent/Legal guardian to sign below You do not need to sign below Consent Statement for applicants under 18 years:

I, (print full name) of (print address) am the parent/ guardian of the above-named (“the minor”) who is under 18 years old. I have read this document and understand its contents, including the exclusion of liability and assumption of risk, and have explained the contents to the minor. I consent to the minor attending/ participating in the event at his/her own risk.

Parent/Legal Date: / / Guardian signature: SIGN HERE (if applicable)

Privacy Statement

CAMS requires the information requested above to assess your application and if accepted, to provide you with membership services. Your personal information, including your health information, will only be used in accordance with the objects of CAMS and CAMS general business. You will be able to access your personal information through CAMS upon reasonable notice. If the requested information is not provided you will not be able to receive membership services. By providing the information you consent to CAMS collecting the health information requested in this application form. I consent to my personal information being used by CAMS’ sponsors or other third parties for the purpose of providing me with promotional material from CAMS’ sponsors and other third parties. Please tick the box if you do not wish to receive any promotional material from CAMS’ sponsors or other third parties. Please return to: CUSTOMER SERVICES, PO BOX 427, CAULFIELD EAST, VIC 3145 www.cams.com.au ©Confederation of Australian Motor Sport Ltd 2012 CAMS HOTLINE 1300 883 959 Page 5 Notes for Application and Renewal of Club National & International Licences INFORMATION FOR ALL LICENCE APPLICATIONS Medical fitness Discipline-specific Licences Applicants for CAMS competition licences must comply with CAMS medical criteria If you compete in more than one licence discipline, eg circuit racing and rallying, you must have all licence categories included on your licence. Pre-licence relevant to their competition level. requirements must be met before a particular category can be added to the licence. Where applicants do not meet the criteria, medical records may be requested by CAMS for referral to State Medical Assessors for a decision on competition fitness. Licence Expiry Dates At first issue, competition and driver licences, except International, will have 12-month expiry dates which will be the last day of the month in which the licence was Applicants will be advised by CAMS if their medical examination or statement has issued; ie, a licence application processed on 15 August, will have an expiry date of not met CAMS medical criteria. 31 August the following year, and this will become the permanent expiry date. Renewed licences will maintain their existing expiry date. It is strongly recommended that all licence holders are vaccinated, where possible, International licences will expire on 31 December of the year of issue to comply against blood borne diseases, eg Hepatitis B etc. with FIA regulations. Licence Photographs Medical Examiners First time applicants for all club national and International applicants should include a recent head and shoulders photograph of passport quality, approximately 40mm Not applicable to National Off Road and National Rally Licences x 50mm. This photo will be used on your CAMS licence. Medical Examinations may be conducted by any registered General Practiioner. Photographs will be stored electronically by CAMS and licence holders will be advised, with renewals, when photographs need to be updated. When making an appointment, please advise that time will be required for a full CAMS Manual of Motor Sport CAMS medical examination. The Health Statement form must be completed by you Applicants for all licence types have the option to receive an abridged copy of the prior to the appointment and the medical examination record will be completed by current CAMS Manual of Motor Sport at no charge. A full version of the Manual can be found online at www.cams.com.au the Medical Examiner.

Pass Books The form must be signed by both you and the Medical Examiner. Make sure A CAMS Pass Book will be issued to new licence holders to provide details of you take the completed Medical Examination form with you when you leave and satisfactory completion of licence upgrade and maintenance requirements and of any penalties applied following judicial procedures. The Pass Book can also be forward it with your licence application, photograph and fee to CAMS. used by licence holders to maintain a competition history. On licence renewal or upgrade of an existing licence an updated licence sticker will be provided to those who have previously been issued with a Pass Book. Lectures and Observed Licence Test For the differing disciplines, new competitors are required to undertake lectures and Licence Performance and Skill Criteria the necessary number of Observed Licence Tests. The performance and skill criteria for competition licences vary between motor sport disciplines. Lectures are completed via the Internet. Applicants should ensure that they meet the appropriate criteria – refer to the Performance and Skill Criteria in the CAMS Manual of Motor Sport online at www. To undertake a lecture via the Internet, the competitor provides details of a current cams.com.au e-mail address in the application form. Further information will be forwarded to this Competitor Licences – Levels J, K, L, M, N & O address. This email will contain a web-link, username and password. The module (Separate application form required) I.D. number and password are requested on the lecture entry screen. Competition vehicle owners who are not the holders of a driver/competitor licence must hold either a Level J, K, L (national) or M, N, O (international) entrant licence. The lecture is undertaken by following the prompts and completing the multiple- Competitor licences may be issued to individuals, companies, groups and teams who are the holders of current CAMS log books. choice test as you go. Sponsor and team names may appear in programs and results without a licence being held. A club affiliated with CAMS may be shown in the program, results etc Observed Licence Test can be arranged by contacting CAMS on 1300 883 959. as the competitor without being required to hold an entrant licence. New applications and advice of company name change must be accompanied by a certificate of incorporation, registration, ACN or business name. Application Advice International Licences In order to complete the efficient production of your licence please consider the (information extracted from Appendix L to the Intl Sporting Code of the FIA) following: Regardless of the category of licence held, Australian nationals participating in international competition overseas must also hold a CAMS-issued visa which • Answer all the questions, they are all important. authorises them to participate in the competition noted on the visa. The highest form of CAMS licence issued is an International Driver/Competitor Licence, which is required • Take your time. Although the information may not have changed, to compete in events of international status both in Australia and overseas. its confirmation ensures that the data we hold is correct. Information can be obtained from CAMS Manual of Motor Sport, Licences. • Check if you need a medical examination. This will be detailed in the Medical Nationality Assessment section of the application form. Applicants who are not Australian citizens must have the authority of the National Sporting Authority of the country of their passport prior to a licence being issued. As • If you do take a prohibited or restricted drug, it does not necessarily mean you required by the Federation Internationale de l’Automobile (FIA). CAMS can arrange cannot compete. Please refer to the ASADA website at www.asada.gov.au. this, but it does take time. You are required to provide documentary evidence of your Australian residential status. This can inlude: • All competitors regardless of discipline must complete a Health Statement, • Appropriate section of your passport each and every year. • Utility bill showing your residential address • Statutory declaration indicating that you are a resident of Australia • Please use current forms. They are available on the CAMS website. www.cams.com.au ©Confederation of Australian Motor Sport Ltd 2012 CAMS HOTLINE 1300 883 959 Page 6 Medical Examination Record Not applicable to National Off Road & National Rally Licences (must be completed by registered Medical Practitioner)

Important If significant abnormalities are found, please obtain specialist opinion or pathology as indicated and return with this form. If doubtful, refer to CAMS Member Hotline — 1300 883 959.

NOTES: 1. Photo ID required. 2. Please attach any Specialists’ reports or any pathology or radiology results relevant to this application. 3. If the applicant wears contact lenses, please attach to this report a certificate from the Ophthalmic Practitioner who fitted them, stating their (i) stability, (ii) duration of daily use and (iii) condition. 4. BMI (i) The Body Mass Index is weight (in kilograms) divided by the square of the height (in metres). (ii) 20-25 Acceptable – normal range 25-30 Health risk area high risk 30-35 Obese } 35-40 Morbidly obese 5. References to Cardiovascular or CV score allude to the Framingham Study. 6. The “normal” answer to each question below is “NO”. In respect of each “YES” response, further details should be provided in Examiner’s Comments.

Member’s name: Member (licence) no: Licence level:

What is the applicant’s: Height (in cm) Weight (in kg) Body Mass Index CV Score

Reference to CV Score chart also required for all applicants. Cardiovascular System ENT System What is the pulse rate? (MAX 100) Is there any evidence of past or present vestibular Yes No Is the rhythm abnormal? Yes No disturbance, including intermittent conditions? Is there any abnormality of the ENT system on What is the blood pressure? (MAX 150/90) / Yes No clinical examination? Are the peripheral pulses abnormal? Yes No Is there any evidence in the history or examination Visual System Yes No of past or present ischaemic heart disease? Yes No Has the applicant any evident abnormality of the eyes? ECG abormal? Yes No Are contact lenses worn? Certificate of Ophthalmic Prac. required if YES Yes No Is an exercise ECG required? (INT’L ONLY) Has the applicant undergone refractive surgery? Yes No Yes No Certificate of Ophthalmic Practitioner required if YES If yes, complete”2” over page Fasting LIPIDS LDL Visual Acuity Test each eye separately with letter chart at 6m HDL Record in metric Snellen notation: eg, 6/9 Fasting GLUCOSE Record number of errors made in smallest line read: eg, 6/9 -3 RE LE Respiratory System Unaided (without contact lenses or spectacles) 6/ 6/ Is there any abnormality of the respiratory system on examination? Yes No Is the applicant a smoker? Yes No With spectacles or contact lenses 6/ 6/ Abdomen Visual fields Is there any abnormality of the abdomen Yes No Do a confrontation test for each eye separately. on clinical examination? Is there any ocular or general medical history that Yes No Urinary Examination suggests the possibility of visual field loss? Does the applicant’s urine contain Protein Yes No Does the confrontation test suggest a loss of visual Yes No Glucose Yes No fields in either eye? Yes No Other abnormality? Colour vision Locomotor System Test with Ishihara for first licence only. 1. Physical deformity, amputation or use Yes No More than three (3) errors is a FAIL indicating abnormal colour vision. of any orthopaedic appliance? Yes No Ishihara test failed? Yes No 2. Is thereTO any impaired BE functional COMPLETED use, BY MEDICAL PRACTITIONER ONLY either from 1 (above) or otherwise? The applicant will most likely need to be referred for a full eyesight examination by an optometrist or an ophthalmologist if the answer Has the applicant impaired use or movement of any Yes No to any question is YES limb, joint, hand or foot which might impair or or compromise control of a motor vehicle? when visual acuity (with glasses if any or unaided if no glasses) is: Central Nervous System – less than a full 6/7.5 in either eye (International Licence) Is there abnormality of the cranial nerves, limb tone, – less than 6/9 -2 in the better eye or less than 6/18 -2 power or co-ordination or tendon or plantar response Yes No in the other eye (National Licence) on examination? The applicant should be given the Vision Report Form to be completed by No Is there any sensory impairment? Yes the optometrist or ophthalmologist they consult. When completed, the form should be returned to CAMS and included with the Medical Examination Record. CAMS will take into account the optometrist/ophthalmologist report when determining the applicant’s fitness to participate in motor sport. Please return to: CUSTOMER SERVICES, PO BOX 427, CAULFIELD EAST, VIC 3145 www.cams.com.au ©Confederation of Australian Motor Sport Ltd 2012 CAMS HOTLINE 1300 883 959 Page 7 Medical Examination Record

Examiners Comments: 1 On history:

2 On examination: Stress ECG (INT’L ONLY) Attach ECG Report. Normal / Abnormal If abnormal, date completed: Other comments:

3 Are there any unfavourable traits in applicant’s personality, revealed by history, appearance or behaviour?

4 Has the applicant been prescribed drugs which are in contravention of the CAMS Anti-Doping policy, or inhaled asthma medications? Yes No

If so, please advise drug, dosage and reason: TO BE COMPLETED BY MEDICAL PRACTITIONER ONLY 5 In your opinion, is the applicant fit to participate in motor sport? Yes No Further assessment

Statement by registered General Practioner

I have personally examined the applicant on / / Signature:

Are you the applicant’s normal GP? Yes No Photo ID sighted Yes No

Name and address of medical examiner:

This medical is only valid for 3 months from the date of examiners signature

Customer Services and State Medical Assessors Use Only

CAMS Member No. Next Exam Due Int Nat Unfit

Medical every Medical every year two years

Medical details to be entered on licence: Visual Correction required? Yes No Other (please specify): Assessor’s signature Date Please return to: CUSTOMER SERVICES, PO BOX 427, CAULFIELD EAST, VIC 3145 www.cams.com.au ©Confederation of Australian Motor Sport Ltd 2012 CAMS HOTLINE 1300 883 959 Page 8